Funeral Cover Application Form - Universal Healthcare
Status House, 15 Tambach Road Sunninghill Park, Sandton PO Box 1411, Rivonia, 2128 Telephone: 086 112 4363 Facsimile: 086 532 6595 E-mail: [email protected] www.universal.co.za Underwritten by Prosperity Life An Authorised Financial Services Provider FSP no.: 1901
Funeral Cover Application Form MAIN MEMBER Surname:
First name/s:
Title:
ID no:
Date of Birth:
Spouse Surname:
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
Y
Y
First name/s:
Title:
ID no:
Date of Birth:
Residential Address:
Postal Address: Postal code:
Postal code:
Telephone no. Home:
Work:
Cell:
E-mail:
Required package:
R
Cover:
A
Monthly premium
R
UNMARRIED CHILDREN/ DEPENDANTS DETAILS (MAXIMUM OF SIX) Full names (Surname first)
Date of Birth
Relationship
1. 2. 3. 4. 5. 6. 7.
EXTENDED FAMILY DETAILS Full names (Surname first)
Date of Birth
ID Number
Relationship
Cover
Monthly premium
1. 2. 3. 4. Total monthly premium
A
B
+
=
B
R
Total
R
NOMINATED BENEFICIARY Full names (Surname first): Title:
Relationship: ID no:
Date of Birth:
METHOD OF PAYMENT EFT
Debit order
Persal
Account holder
Account type:
Account number:
Bank:
Branch name:
Branch code:
Commencement date:
Please debit my account of the
day each month.
Personal no.
D
D
M
M
Y
Y
DECLARATION I declare that the information supplied above is to the best of my knowledge true, complete and correct. I hereby authorise Prosperity Life and/or its Agents to draw against my account, the premium payable under the above plan from time to time, and I request my bank to debit my account in terms of the order. This request will remain in force until cancelled by me in writing. I hereby irrevocably authorise Prosperity Life and/or its Agents to obtain at any time, verification of my account details from my bank.
DECLARATION OF HEALTH 1.
Are you , your spouse, dependants and/or extended family in good health?
Yes
2.
If “No”, specify any medical complaint fully (Policyholder, spouse, dependants, extended family)
No
D
ACCOUNTHOLDER’S SIGNATURE
POLICYHOLDER’S SIGNATURE
D
M
M
Y
Y
Y
Y
DATE
TERMS AND CONDITIONS a) b) c) d) e) f) g) h)
i) j) k) l) m) n) o) p) q) r)
No maximum age for policy holder applications. No maximum age for extended family policy applications. Scheme covers policy holder, spouse and unmarried children under 22 years of age or 25 years inclusive if the child is at a recognised educa¬tional institution and is still classified as a dependant. A one month waiting period is effective if a member dies within the standard waiting period as a result of an accident. Premiums are payable monthly in advance in full, to ensure cover for the month. Cover commences on receipt of the first premium. Claims will be settled within 48 working hours after all relevant documentation has been received. Failure to submit a claim within three months of the date of death will render the claim null and void. Cover will cease automatically upon the non-payment of premium and the policy will lapse. However, the policy can be re-instated by the policy holder and the following will apply: (i) The outstanding premium must be paid within 15 days of the due payment date. (ii) The relevant waiting period/s will once again be applicable from the new date of commencement of payments. It is not the responsibility of the underwriter to cover any member when the premium has not been paid. Premiums are payable lifelong, there are no surrender values and a policy may not be ceded. Mentally, physically and/or permanently and totally disabled children approved by the underwriter are covered until their death or as long as the policy holder participates in the Scheme. Stillborn infants will only qualify for consideration of payment if the following criteria are met: The foetus must have attained a minimum gestation period of 26 weeks and any claim submitted must in addition to the usual claim documentation be accompanied by a form BI-1663. In addition, a certificate confirming the number of weeks at termination of the pregnancy must be obtained from the attending doctor or gynaecologist. Common law as well as civil marriages are recognized by the Scheme. Only one spouse is allowed as a dependant for the policy holder. Application forms must be fully and accurately completed by the policy holder, reflecting full names, dates of birth and identity document numbers of all persons that are to be covered, assisted by the agent where necessary. Premium rates will be reviewed regularly on the Scheme anniversary date although they may be adjusted at any time if so necessitated by the Scheme’s experience. Should it come to the attention of the underwriter that any of the information provided is not accurate, membership under the policy can be cancelled and no claim from the Scheme will be considered. Maximum cover available under any one policy is R10 000.00 Should a claim arise within the first 12 months from date of inception, the underwriter reserves the right to request a BI-1663 or a medical certificate. The underwriter also reserves the right to request any additional information that may be required to process a claim. The onus is on the beneficiary to obtain and provide to the Underwriter both pages of the BI-1663 in the event of a claim. A claim may be withheld if this documentation is not provided. No policy holder, spouse, child/children, dependant/s or any extended family member/s may be listed on any other (or more than one) Prosperity application document relevant to the same Scheme/Group or individual policy, i.e. more than one claim payout for the same individual is not permitted. This does not apply to cover of R7 500 to R18 000 (two or more policies). The policy holder has the right to view the Master Policy at a Prosperity office.
Waiting Periods: 1. 2.
3.
4. 5.
For cover of R2 000, R5 000, R7 500 and R18 000 a. Under 66 years of age: 0 months waiting period for Lifestyle 360° and medical aid members administered by Universal Healthcare. b. Suicide: 24 months waiting period. For cover of R1 000-R10 000 a. 66-74 years of age: 9 months waiting period. b. 75 years and older: 12 months waiting period. c. Suicide: 24 months waiting period. Cover of R1000 - R10 000 for extended family a. Under 65 years of age: 6 months waiting period. b. 65 – 74 years of age: 9 months waiting period. c. 75 years and older: 12 months waiting period. d. Suicide: 24 months waiting period. Outstanding premium during waiting period Payment of premiums during waiting period must be continuous, i.e. no payment may be outstanding or paid late. If a payment is outstanding or paid late, the policy will lapse and the applicable waiting period will begin again from the date that payments are resumed.
Funeral Cover Application Form MAIN MEMBER Surname:
First name/s:
Title:
ID no:
Date of Birth:
Spouse Surname:
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
Y
Y
First name/s:
Title:
ID no:
Date of Birth:
Residential Address:
Postal Address: Postal code:
Postal code:
Telephone no. Home:
Work:
Cell:
E-mail:
Required package:
R
Cover:
A
Monthly premium
R
UNMARRIED CHILDREN/ DEPENDANTS DETAILS (MAXIMUM OF SIX) Full names (Surname first)
Date of Birth
Relationship
1. 2. 3. 4. 5. 6. 7.
EXTENDED FAMILY DETAILS Full names (Surname first)
Date of Birth
ID Number
Relationship
Cover
Monthly premium
1. 2. 3. 4. Total monthly premium
A
B
+
=
B
R
Total
R
NOMINATED BENEFICIARY Full names (Surname first): Title:
Relationship: ID no:
Date of Birth:
METHOD OF PAYMENT EFT
Debit order
Persal
Account holder
Account type:
Account number:
Bank:
Branch name:
Branch code:
Commencement date:
Please debit my account of the
day each month.
Personal no.
D
D
M
M
Y
Y
DECLARATION I declare that the information supplied above is to the best of my knowledge true, complete and correct. I hereby authorise Prosperity Life and/or its Agents to draw against my account, the premium payable under the above plan from time to time, and I request my bank to debit my account in terms of the order. This request will remain in force until cancelled by me in writing. I hereby irrevocably authorise Prosperity Life and/or its Agents to obtain at any time, verification of my account details from my bank.
DECLARATION OF HEALTH 1.
Are you , your spouse, dependants and/or extended family in good health?
Yes
2.
If “No”, specify any medical complaint fully (Policyholder, spouse, dependants, extended family)
No
D
ACCOUNTHOLDER’S SIGNATURE
POLICYHOLDER’S SIGNATURE
D
M
M
Y
Y
Y
Y
DATE
TERMS AND CONDITIONS a) b) c) d) e) f) g) h)
i) j) k) l) m) n) o) p) q) r)
No maximum age for policy holder applications. No maximum age for extended family policy applications. Scheme covers policy holder, spouse and unmarried children under 22 years of age or 25 years inclusive if the child is at a recognised educa¬tional institution and is still classified as a dependant. A one month waiting period is effective if a member dies within the standard waiting period as a result of an accident. Premiums are payable monthly in advance in full, to ensure cover for the month. Cover commences on receipt of the first premium. Claims will be settled within 48 working hours after all relevant documentation has been received. Failure to submit a claim within three months of the date of death will render the claim null and void. Cover will cease automatically upon the non-payment of premium and the policy will lapse. However, the policy can be re-instated by the policy holder and the following will apply: (i) The outstanding premium must be paid within 15 days of the due payment date. (ii) The relevant waiting period/s will once again be applicable from the new date of commencement of payments. It is not the responsibility of the underwriter to cover any member when the premium has not been paid. Premiums are payable lifelong, there are no surrender values and a policy may not be ceded. Mentally, physically and/or permanently and totally disabled children approved by the underwriter are covered until their death or as long as the policy holder participates in the Scheme. Stillborn infants will only qualify for consideration of payment if the following criteria are met: The foetus must have attained a minimum gestation period of 26 weeks and any claim submitted must in addition to the usual claim documentation be accompanied by a form BI-1663. In addition, a certificate confirming the number of weeks at termination of the pregnancy must be obtained from the attending doctor or gynaecologist. Common law as well as civil marriages are recognized by the Scheme. Only one spouse is allowed as a dependant for the policy holder. Application forms must be fully and accurately completed by the policy holder, reflecting full names, dates of birth and identity document numbers of all persons that are to be covered, assisted by the agent where necessary. Premium rates will be reviewed regularly on the Scheme anniversary date although they may be adjusted at any time if so necessitated by the Scheme’s experience. Should it come to the attention of the underwriter that any of the information provided is not accurate, membership under the policy can be cancelled and no claim from the Scheme will be considered. Maximum cover available under any one policy is R10 000.00 Should a claim arise within the first 12 months from date of inception, the underwriter reserves the right to request a BI-1663 or a medical certificate. The underwriter also reserves the right to request any additional information that may be required to process a claim. The onus is on the beneficiary to obtain and provide to the Underwriter both pages of the BI-1663 in the event of a claim. A claim may be withheld if this documentation is not provided. No policy holder, spouse, child/children, dependant/s or any extended family member/s may be listed on any other (or more than one) Prosperity application document relevant to the same Scheme/Group or individual policy, i.e. more than one claim payout for the same individual is not permitted. This does not apply to cover of R7 500 to R18 000 (two or more policies). The policy holder has the right to view the Master Policy at a Prosperity office.
Waiting Periods: 1. 2.
3.
4. 5.
For cover of R2 000, R5 000, R7 500 and R18 000 a. Under 66 years of age: 0 months waiting period for Lifestyle 360° and medical aid members administered by Universal Healthcare. b. Suicide: 24 months waiting period. For cover of R1 000-R10 000 a. 66-74 years of age: 9 months waiting period. b. 75 years and older: 12 months waiting period. c. Suicide: 24 months waiting period. Cover of R1000 - R10 000 for extended family a. Under 65 years of age: 6 months waiting period. b. 65 – 74 years of age: 9 months waiting period. c. 75 years and older: 12 months waiting period. d. Suicide: 24 months waiting period. Outstanding premium during waiting period Payment of premiums during waiting period must be continuous, i.e. no payment may be outstanding or paid late. If a payment is outstanding or paid late, the policy will lapse and the applicable waiting period will begin again from the date that payments are resumed.
